Form Na 281b - Notice Of Action (Continuation Page) - Underpayment Amount Owed (For Underpayments Occurring On Or After 10-1-2013)
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1NOTICE OF ACTION
COUNTY OF
STATE OF CALIFORNIA
HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
(Continued)
Notice Date : ____________________________________________________________________________
Case
Name
: ____________________________________________________________________________
Underpayment Amount Owed
Number
: ____________________________________________________________________________
(For Underpayments Occurring on or after 10-1-2013)
Worker
Name
: ____________________________________________________________________________
Number
: ____________________________________________________________________________
Underpayment month and year:
Monthly Cash Aid Amount
Section A. Countable Income, Month of ___________
1.
Self-Employment Income . . . . . . . . . . . . . . . . . . . . . . $ ____ _________
2.
Self-Employment Expenses:
a. 40% Standard . . . . . . . . . . . . . . . . . . . . . . . . . . . . - _____________
OR
b. Actual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - _____________
3.
Net Earnings from Self-Employment . . . . . . . . . . . . . = _____________
4.
Total Disability-Based Unearned Income (DBI)
(Assistance Unit + Non-Assistance Unit Members) . $ _____________
5.
$225 DBI Disregard (if #4 is greater than $225) . . . . - _____________
6.
Nonexempt Unearned Disability-Based Income . . . . = _____________
OR
7.
Unused DBI Disregard . . . . . . . . . . . . . . . . . . . . . . . . = _____________
8.
Net Earnings from Self-Employment (from above) . . + _____________
9.
Total Other Earned Income . . . . . . . . . . . . . . . . . . . . + _____________
10. Unused Amount of $225
(from #7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - _____________
11. Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = _____________
12. Earned Income Disregard 50%. . . . . . . . . . . . . . . . . . - _____________
13. Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = _____________
14. Nonexempt Unearned Disability-Based Income
(from #6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . + _____________
15. Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = _____________
16. Other Nonexempt Income (Assistance Unit + Non-
Assistance Unit Members) . . . . . . . . . . . . . . . . . . . . . + _____________
Net Countable Income . . . . . . . . . . . . . . . . . . . . . . . . . . = _____________
Section B. Your Cash Aid, Month of ____________
1.
Maximum Aid ______ Persons
(Assistance Unit + Non-Assistance Unit Members) . . $ _____________
2.
Special Needs (Assistance Unit + Non-Assistance
Unit Members) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . + _____________
3.
Net Countable Income from Section A (above) . . . . . - _____________
4.
Subtotal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = _____________
5.
Maximum Aid ______ Persons (Assistance Unit only)
(Excluding MFG, or Penalized Persons) . . . . . . . . . . $ _____________
6.
Special Needs (Assistance Unit only) . . . . . . . . . . . . + _____________
7.
Maximum Aid Subtotal . . . . . . . . . . . . . . . . . . . . . . . . = _____________
8.
Full Month Aid Subtotal
(Lowest Amount on Line 4 or 7) . . . . . . . . . . . . . . . . . = _____________
9.
Line 8 Prorated for Part of Month . . . . . . . . . . . . . . . . = _____________
10. Adjustments: 25% Child Support Penalty(ies) . . . . . . - _____________
Other Penalties . . . . . . . . . . . . . . . . . . - _____________
Overpayment . . . . . . . . . . . . . . . . . . . . - _____________
Cal-Learn Penalties . . . . . . . . . . . . . . . - _____________
School Bonus ($100 or $500) . . . . . . . + _____________
11. Monthly Cash Aid Amount
(Line 8 or 9 Adjusted) . . . . . . . . . . . . . . . . . . . . . . . . . $ _____________
Underpayment
Correct Cash Aid Amount . . . . . . . . . . . . . . . . . . . . . $ _____________
Cash Aid Paid To You . . . . . . . . . . . . . . . . . . . . . . . . . - _____________
Subtotal . . . . . . . . . . . . . . . . . . . . . . . = _____________
Amount of Underpayment for Each Month . . . . . . = _____________
TOTAL UNDERPAYMENT (All Months)
$ ____________
State Hearing: If you think this action
Rules: These rules apply; you may review them at your
is wrong, you can ask for a hearing.
Welfare Office: MPP 44-340, SB 1041 (Chapter 47, Statutes of 2012).
The back of Page 1 tells how.
Page____ of ____
NA 281B (5/13) CONTINUATION PAGE - (UNDERPAYMENT COMPUTATIONS ON OR AFTER 10-1-2013)
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